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Home My Public Portal About6149 AVON AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT '•I hereby offi+m that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, 76A3e4c HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab. C.) CE-818(REV. 10/81) Policy No. Company Certified copy is hereby furnished. COUNTY OF-LO.S ANGELES BUILDING AND SAFETY .Certified copy is filed with the county building,inspec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS (PRINT OR TYPE ONLY) Date Applicant LOCALITYiF l� ppLZT- C/ 117 7S- NO. TYPE OF APPLIANCE OR EQUIPMENT FEE '-I/ CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. 6VJ P,11 P,4 (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSE(2 BY the permit is for one hundred dollars ($100)or less.) AIR HANDLING UNIT, CFM ( JJ I certify that in the performance ofthework for which this � - permit is issued, I shall not employ any person in any manner so as to become subject to the Work s'CO pen do Laws. BOILER, BTU APPROVALS DATE INScOR'S SIGNATURE Dated-Z Applicant COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: If, after making This Certif' ate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the 'Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU Q I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT- '(commencing USPENDED UNIT WALL _ (commencing with Section 7000) of Division 3 of the Business � and Professions Code,and my license is in full force and effect. License Number Lic. Class - , V O� Contractor Date V I am exempt under Sec. us Plan check fee 1116 B.&P.C. for this reason � PERMIT ISSUING FEE $ Q d ;2 3 4 4,4 A Date: Signature TOTAL FEE # o,0 o e 0 8 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT _ 0 e20.50 I hereby affirm that I am exempt from the Contractor's License o o a Law for the following reason (Section 7031.5, Business and NAME v,. ( - Professi Code): I, as owner of the property, or my employees with ADDRESS wages as their.sole compensation, will do the work and the structure is not intended or offered for sale(Section CITY TEL. NO. 7044, Business and Professions Code). J� r q /► OWNER El 1, ©roo- ls',ler CO I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL � tion 7044, Business and Professions Code). ADDRESS vow CONSTRUCTION LENDING AGENCY CITY Fbi Pi.C_- f •fEL. NO. I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR 5 (Sec. 3097, Civ. C.). ADDRESS Lender's Name CITY TEL. NO. Lender's Address I Certif that I have read this application and state that the STATE LIC. Y pp LICENSE NO. CLASS above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, andher by authorize representatives of this County to enter upon ab e-me property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Age t Date